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please use the information on the attached paper and fill out the care plan.
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School of Health Professions, Science and Wellness
Department of Nursing
CLINICAL CARE PLAN GRADING CRITERIA
Course Number: ______________________________________
Name of Student: _____________________________________
Date:________________________________________________
Grading Criteria
Possible
Points
Section I
General Data, Submission due date
Section II
Recognizing cues
Visual assessment
Physical assessment
Medical Surgical history
Vital signs
Labs & procedures
Section III Analyzing cues
Hypothesizing
Form Hypothesis
Hypothesis for future action
Medication sheet
Section IV
Responding & Taking Action
5 POINTS
Safety
Immediate Interventions
Delegation
Family teachings
Response to family
5
5
5
5
5
Section IV
Reflecting & Evaluation
25 POINTS
Evaluations of actions
20 POINTS
15 POINTS
2
3
3
2
5
30 POINTS
5
5
10
10
25 POINTS
Points Earned/Comments
Grading Criteria
Possible
Points
References
5
TOTAL POSSIBLE POINTS
100 POINTS
Points Earned/Comments
Name of Clinical Professor: ____________________________________________
Overall Comments:
School of Health Professions, Science and Wellness
Department of Nursing
Clinical Care Plan
Professional Nursing Foundations
Semester: ___________________
Total points awarded: __________________
Student: ____________________________________ Date: __________________
Instructor: ______________________________
Section I
General Data
(Points 5)
Obstetrical History:
Maternal Data:
G
T
P
A
L
Due Date (EDC)
Prenatal Care- YES or NO
Date of Past Delivery
Type of Delivery
Anesthesia
Current Delivery Date
Type of Delivery
Anesthesia
Significant History
Newborn Data:
Gestational Age
Weight______gm/______lb____oz
Apgar
Feeding- Breast or Bottle
Other issues(e.i, GDM, PTL, HTN)
____________________________________________________________________
____________________________________________________________________
Prenatal Labs:
ABO:_____
Rubella:________ HIV_______ Hep B.:______ RPR:________ GBS:_________
Gonorrhea:_________ Chlamydia:_____________
Current CBC: Hemoglobin:_________Hemacrit:_________ WBC:_______ Platelets:___________
UA:________________________________ Urine Drug Screen:___________________________
Other Significant labs/Ultrasound Results:
_____________________________________________________________
Section II
Recognizing Cues
(Points 15)
NOTICING – UTILIZING OBSERVATIONS TO RECOGNIZE PATTERNS, AND GATHER INFORMATION.
RECOGNIZING CUES – The mental process involved in identifying relevant and important information
60 second initial visual assessment
(Completed while receiving report and prior to physically assessing patient)
What do you
see?
Visual cues such
as room
cleanliness,
hygiene of
patient, IV pump,
O2, other lines,
drains, tubes.
Focused Physical Assessment
Recognize abnormal vs. normal – Recognizing signs and symptoms
What is your
client’s admitting
diagnosis?
What will you
focus on based
on this
information?
Perform
appropriate
focused
assessment.
Include the
findings of your
focused
assessment
Include the
pathophysiology
of the client’s
admitting
diagnosis,
including the risk
factors,
signs/symptoms,
diagnostics,
prognosis, and
treatments. You
must include a
resource for this
information. (1-2
pages)
Identify History Of
Medical/Surgical/Home Medication/Social, Occupational History cues
Recognize contributing past history
Interview your
patient.
What is their
pertinent
medical/surgical
history?
What home meds
do they take?
Where do they
work, live,
socialize?
Vital Signs, Lab Values and Diagnostics
Recognize abnormal vs. normal as well as pertinent information related to patient diagnosis
Temp:
Document the
Blood Pressure:
patient’s vital
signs.
Heart Rate:
Include reasoning
for any abnormal Respiration:
vital signs.
Pain:
Lab
Value
Examine your
patient’s
Electronic
Medical Record.
What are the
pertinent lab
values given the
admitting
diagnosis and
current condition
of your patient?
What diagnostic
tests has the
client
undergone?
Include the
results of the
test.
Normal
Range
Patient’s
Lab Value
Result
Reason for Abnormal Value
Section III
Analyzing Cues & Prioritize Hypothesis
(Points 30)
INTERPRETING – MAKING SENSE OF THE DATA AND PRIORITIZING INFORMATION
UTILIZING YOUR REASONING ABILITIES TO INTERPRET THE FACTS AND FORSEE POSSIBLE INTERVENTIONS
ANALYZING CUES – clustering and linking related information to create groups of individual cues
PRIORITIZE HYPOTHESIS – Evaluate and rank potential causes or risk factors to address
Based on findings from 60 second initial visual assessment
Hypothesize regarding needed interventions
What will require
action?
Prioritizing action (i.e.
bathe patient, tidy
room, fluid
replacement, adjust O2
etc)
Based on findings from Focused Physical Assessment
Analyze and form hypothesis for future action
What assessment
findings are most
concerning?
What makes you say
that?
Are there any findings
that seems
contradictory? (i.e.
findings that may point
to an alternative or
additional concern)
What findings are
consistent with
admitting diagnosis?
Based on Identifying History Of
Medical/Surgical/Home Medication/Social, Occupational History cues
Analyze and form hypothesis for future action
What findings did you
expect based on the
client’s
diagnosis/concern?
What medications
would you expect based
on the client’s diagnosis,
concern, history?
Are there any findings
that seem
contradictory? (i.e.
meds expected but not
present, meds present
but not expected,
assessment findings
without interventions)
What else could be
going on?
Based on Vital Signs, Lab Values and Diagnostics
Analyze and form hypothesis for future action
What will require
action? (i.e. b/p
requiring treating,
increase or decrease O2,
treat electrolyte
imbalance, intervene
regarding fluid volume
status, etc.)
GENERATE SOLUTIONS – Generate a set of feasible solutions to handle emergent concerns based on prioritized
hypothesis above
Things to address?
Things to avoid?
What interventions are
indicated?
Which hypothesis is the
most important and
should be managed
first?
What makes you say
this?
Medication Sheet (10 points)
Medication Dose
Generic Name
Mechanism of
Action/Indication
for Use
Contraindication
Adverse
Effects/Side
Effects
Nursing
Implications
Outcomes
Section IV
Responding & Taking Action
(Points 25)
RESPONDING – UTILIZING YOUR CLINICAL JUDGMENT TO MAKE DECISIONS AND JUDGMENTS
TAKE ACTION – Implementation of the solutions based on generated hypothesis
Based on generated solutions
What are the critical safety
issues and what did you do
to protect the client?
What interventions are
needed immediately? How
will you implement them?
What interventions can be
delegated and to whom?
What specific items will you
teach the client? Health
teachings given?
How did you respond to
patient, family and
caregivers?
Section IV
Reflecting & Evaluation
(Points 25)
REFLECTING – EVALUATION OF PERSONAL EXPERIENCE AND UTILIZING JUDGMENT SKILLS
EVALUATING OUTCOMES – Understanding signs of clinical improvement or decline and reflecting on the
effective outcomes of interventions
What follow-up data are
needed?
What findings show
interventions have been
effective?
What interventions require
formulating a new
hypothesis?
What values show a need for
continued monitoring (i.e.
labs, vital signs, interventions)
What went well and what did
not go well and why?
What would you do
differently?
What priorities, skills do you
think you need to improve in
order to care for future
patients?
References: (5 Points)
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